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TOPIC: Determinants of Breast Self-Exam for early detection of breast cancer among women in Kenya.

INTRODUCTION.

Globally cancer is an emerging health concern, with an estimated 18.1 million cases and 9.6 million deaths reported in 2018. It is estimated that one in 5 men and one in 6 women will develop cancer in their life time. Increasing cancer prevalence globally has been to linked to several factors allied to the changing prevalence of cancer causing agents and factors linked to social- economic development. Infact cancer incidence rates in countries with high HDI is 2-3 times that of countries with low HDI but with similar mortality patterns observed. This has partly been attributed to the fact that countries with low HDI lack timely access to effective treatment diagnosis. Breast cancer is reported to be the most commonly occurring cancer among women globally and the second cause of cancer mortality after lung cancer in both sexes, with over 2M new cases reported in 2018. Even more worrying is the fact that Majority of these cases (70%) are reported to come from low and middle income countries, who may lack the capacity to curb the problem due to resource constrains.( Bray et al., GLOBOCAN 2018, WHO 2018). Comparing with the global burden, Africa is reported to have higher proportions of mortality cases to cancer in contrast to their incidence rates at 7.3% and 5.8% respectively. ( WHO 2018) ( WCRF 2019) ).

Breast cancer prevention, early diagnosis and management have over time been recommended in order to curb adverse outcomes associated with breast cancer. Various challenges have however been cited to contribute to inadequate breast cancer services in the including, lack of funds, poor health infrastructure( personnel, equipment, referral system), lack of mammograms, and low community awareness amongst other healthcare systems related challenges. ( Panieri et al., 2012, Anderson et al., 2006). Additionally, low-level knowledge of early signs and symptoms has also contributed to late presentation and diagnosis.( J. Kisuya et al., 2015) The general belief that breast cancer is incurable has also been cited to delay health seeking behavior of many women , who opt to explore other culturally acceptable options , presenting to the hospital as a last resort.( Muchiri M. 2006)

Breast Self -Exam is inspection of one’s breast using the eyes and feeling with the hands to detect any changes to one’s breasts and its accessories. ( Mayo 2014). The use of BSE was first advocated by the ACS not as a diagnostic method but as contribution to screening , with a recommendation that women beginning from their early 20’s be informed on the benefits of BSE and taught on the technique which is to be reviewed regularly. Use of BSE is however not made mandatory and even those practicing BSE are allowed to choose not to do it on a regular pattern. ( Ibnawadh et al., 2017) However, Jon Hopkins University amongst other institutions on breast cancer, recommends that every adult woman regardless of age should perform a Breast self-exam (BSE) at least once a month at the same time interval between one exam to the next. ( Hopkins 2019)

Statistics have shown that most (90%) of the breast cancers diagnosed are actually by the women themselves discovering lumps in their breasts either accidentally or deliberately. ( Huguley et al., Mendelson 2003). The practice of Breast self-exam has been shown to empower women take responsibility of their own health and has been recommended in order to increase awareness among women of breast cancer as any changes would prompt the woman to seek medical attention and hence detect and diagnose breast cancer early enough for timely interventions. Women who practice BSE have been shown to have early breast cancer diagnosis than those who don’t . (Gastrin et al., 1994; Auvinen et al., 1996) Five year survival from breast cancer has also been shown to increase to 85% due to early detection of breast lumps and any other breast abnormalities (Ibnawadh et al.,2017), (Halall 1982). Studies have shown that women practicing regular BSE presented with small tumours and with less spread of the cancer to the axillary lymphnodes. Survival therefore, from breast cancer has been shown to improve greatly as awareness increases with the risk of advanced disease and early mortality also decreasing among women practicing BSE. ( Richard et al., 2000, Mayo 2019, WHO 2019).

The efficacy of using BSE as a screening modality for breast cancer has however been controversial due to the fact that studies done have not demonstrated decrease in mortality associated with its use as opposed to use of mammography. (Thomas et al., 2002), This fact however doesn’t undermine the role of BSE in early detection of breast cancer and hence saving lives. Its role has been demonstrated to be key especially in the developing countries where mammography is unaffordable or even inaccessible to majority of the women from the lower socio-economic backgrounds. (SY Loh and SL Chewet,2011). In addition use of mammography and CBE for breast cancer diagnosis involves one visiting a hospital which has the capacity to offer these services, while use of BSE is cost-free and easy to use once a woman has been taught the technique. (Okobia, Bunker, Okonofua, & Osime, 2011)

The practice of BSE has variedly been low across regions with various challenges quoted as contributing to the low intake of the practice despite the documented evidence of its potential benefits. Reasons like lack of confidence in the technique, lack of time, fear of discovering breast lumps hence cancer, amongst others have been cited. (Lierman, Young, Powell-Cope, Georgiadou, & Benoliel, 2014). A study carried out showed that just 54% of the population in England and 52% in India carried out BSE. (Yadav & Jaroli, 2010). Similarly, another study showed that 41.9% in Iran had performed BSE in the past while only 7.6% had done it regualrly. Uptake of BSE in many African countries has also been low with studies recommending an increase on its knowledge and awareness. (Haji-Mahmoodi et al., 2002).

Empowering women with BSE has been recommended as a primary modality for screening for breast cancer in low income resource settings due to lack of or in-accessible diagnostic facilities. ( Wilke et al., 2009)

In Kenya , Breast cancer is still the leading cancer reported in both sexes combined with an incidence of 34 per 100,000 in women presenting the highest cancer related mortality and morbidity rates and closely followed by cervical cancer which has a case rate of 25 per 100,000 women.( GlOBOCAN 2018).

Recent data shows that Majority of the women diagnosed with breast cancer in kenya are between 35 – 45 years a worrying trend since most of these women are at their peak of productive life, hence the need for early diagnosis and management. (wachira et al ., 2014). Most of the cancer cases in Kenya like in other sub-saharan African countries are unfortunately characterized by late presentation, with the majority (70- 90%) diagnosed while in stage III or IV, where management may be much more expensive, intensive and Prognosis very poor. (Fregene et al., 2005

The ministry of Health in the National cancer screening guidelines recommends use of mammogram as the mainstay screening modality for breast cancer, while use of Breast self- exam (BSE) and clinical breast exam (CBE) as complimentary to it, and hence advocacy for the latter two modalities have somehow been silent

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